Category Archives: Direct Practice

Crossover Health: Welcome to Next Generation Health Care!

Crossover Health Launches New Model of Primary Care in South Orange County
Innovative membership service delivers Urgent, Primary, and Online Care

Aliso Viejo, CA (PRWEB) October 1, 2010

Crossover Health Medical Group announced today the launch of their flagship membership-based, primary care practice in Aliso Viejo, California. The new clinic will offer urgent, primary, and online care services directly to individual members, families, and employer groups. Membership based health care is a new health care finance and delivery innovation that has gained widespread popularity as the cost of health insurance and ongoing service deficiencies have plagued the current health care delivery system. The Crossover membership model decouples health care from health insurance, and allows individuals and organizations to purchase primary care directly from health care providers who offer increased access, enhanced services, and an exceptional service experience.

“The membership-based practice model allows Crossover Health to fundamentally change the way health care is practiced, delivered, and experienced,” according to Chief Executive Officer Scott Shreeve, MD. “Crossover has been specifically designed to restore and enhance the patient-physician relationship, increase access and convenience, reduce the cost of health care, and deliver an unprecedented patient experience.” The membership fee pays for access to the technology enabled practice and wellness services, as well as affordable prices for office visits, specialty consultations, and ongoing health management followups. A health concierge is assigned to each member to assist in overseeing follow-ups, proactive health maintenance, and care coordination. Crossover also provides health advisory services to guide patients in financial decisions related to the management of their health.

Crossover Health introduces two key innovations to the membership model. First, Crossover members have direct access to their physician via Crossover’s unique online, anytime, from anywhere technology platform that includes options for email, text, and video chat consultations. Second, the technology also enables a direct financial, administrative, and clinical relationship between the patient and their personal physician and the extended Crossover care team of medical specialists, diagnostic testing centers, and other licensed professionals. This inherent connectivity enables the creation of the Crossover Health Network™, a network of specialist providers who commit to deliver to a specific service level, make their prices transparent to members, and communicate on a common platform. The result is a simple, efficient, and affordable care experience.

“Many people, including employers, are surprised to find out how affordable exceptional health care can be when purchased directly from the physician,” said Chief Medical Officer Richard Patragnoni, MD. “Members can typically save a significant amount of money while enjoying a broader range and higher quality of personalized service to meet individual, family, or corporate health needs.” Crossover offers a variety of individual and corporate memberships that provide essential primary and preventive care services as well as targeted wellness programs like medical weight loss, executive health programs, health portfolio management, and virtual clinics.

Crossover Health memberships appeal to individuals looking to establish a personal relationship with a physician, families whose care requires a higher service level, and busy professionals who need flexible access to their physician. Membership care is particularly attractive to employers facing annual double digit health care cost increases. Employers using this model have consistently shown significant reduction in inappropriate utilization, dramatic improvements in satisfaction, and cost savings of up to 50% when bundled with lower premium insurance plans. Crossover Health is currently accepting new members throughout the Orange County area.



Filed under Change Agents, Crossover, Design, Direct Practice, Entrepreneurship, Innovation, Launch, Medical Home, Membership, Primary Care, Quality, Value

Day 65: Proof is in the Passion – Crossover Explained


Tonight I attended an awesome charity event called Savannah’s Organic Ranch. Savannah was a beautiful girl stricken with cancer whose last wish was to pass along her love of organic farming. The spark that was her life and encapsulated in her last wish has fueled a community wide passion for spreading representative organic “ranches” at local schools and in our community. I was impressed with the passion of this young girl, and how it has inspired equally vibrant passion for those who wish to keep her memory alive for a great cause.

I believe passion is an integral part of life and anyone’s life’s work. At several forks in my professional journey, I have chosen to pursue my passion instead of settling for a more secure road. It has been a defining characteristic in my life – one in which I have occasionally questioned during challenging times but have always known was my destiny. I find myself once again passionate about what I am attempting to do, and the familiar sense of being energized by both the general impossibility of the task at hand coupled with the equally strong sense of inevitability with which all entrepreneurs are endowed.

Instead of writing it out, I thought I would just capture what I am doing on video:

Saves me time, provides some strong visualization of our business, and hopefully conveys the passion I feel about what we are doing.  We will be using this blog and our other channels to tell our evolving story, as well as the entrepreneurial extremes we experience as we drive toward launch. Hope to make this a dialogue as we roll forward.

* For those of you wondering whats up with our broken down building, this video was shot by Benny Ek Media within our new space following its demolition. We look forward to introducing our new design, look and feel.


Filed under Consumerism, Crossover, Direct Practice, Leadership, Uncategorized, Value

Day 84: Taglines for a New Business Model

Tagline (tăg’līn’) n.

  1. An ending line, as in a play or joke, that makes a point.
  2. An often repeated phrase associated with an individual, organization, or commercial product; a slogan.

An exciting opportunity as part of our opening a clinic is the ability to communicate new messaging around what it is we do. I am passionate about the membership-based primary care model as the means to bring about major reform within our current health care system. However, convincing patients of the value of the membership model takes significant work particularly at this early stage of the introduction of the model. Early pioneers like QLiance and Current Health have been successful but it has been a long, tough slog. In fact, I would argue that the core competency to effectively convince and convert patients to this new model will be the differentiator in those pursuing this model.

To that end, we have been assiduous in our approach to messaging. Our developing model is to provide excellent access through our urgent care, deliver a service experience that dazzles the patients, create an incentive to become a member of our practice, and as a member have access to a wide array of innovation communication tools that make online, anytime, and anywhere health services possibles. These capabilities got us thinking about how we should position this to the patients who are unfamiliar with our model. We came up with the following as a visual sign to the 75,000 or so cars that pass by our walls every day:

Our thinking above heavily influenced the order of wording as well. We believe that the urgent care is the draw that brings patients in, the membership based primary care is what keeps them engaged, and our enhanced capabilities help them experience the power of the new model. This wasn’t without angst as we debated if people would even understand the term online care. We reasoned that most people would not get it but it was interesting enough that we believe they will go online to our site to figure out what it is. “Online Care” is a term that is not yet owned, (American Well has promoted the term effectively), but that we could seriously influence its adoption and our pioneering of it here in OC.

We went through multiple variations of colors, sizing, and shapes but ended up with the above as a functional tagline above. We also had to decide multiple iterations of lighting, backlighting, halogen, etc. And of course, for good measure, we were hit with having to remove and repair the old signs.

For interest, a couple of other variations follow below:

Alternative Approach to Signage Project

Alternative Approach 2 to Signage Project

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Filed under Direct Practice, Launch, Uncategorized

CPT Codes-Why physicians always get screwed, thanks AMA

CPT Codes

  1. Set of health care procedure codes based on the American Medical Association’s Current Procedural Terminology
  2. Established in 1978 to provide a standardized coding system for describing specific items and services provided in delivering health care.

Daniel Palestrant comes right back from his opening salvo of last week to continue his crusade against the AMA. In another hard hitting email blast sent out to his 100,000 physician community he lays out the case of how the CPT system, maintained and propagated by the AMA, actually holds physicians hostage to the insurance cycle of care. He also lays the groundwork for the new retail health care economy where CASH will be king, relationship with the provider will be DIRECT, and physicians and patients will once again re-establish a relationship built on trust, advocacy, and professionalism.

This should be put in context with the recent announcement that Qliance just received $4M, Hello Health continues on an unprecendented media tear, and groups like Current Health and Crossover Health can emerge in this reality for American medicine. Whether or not we actually end up with health reform this year, you can be assured that Americans will want a separate system of “off the grid” providers.

July 8, 2009

Dear Dr. Shreeve,

In the healthcare debate it is rare that we find a single issue that all parties can agree is a big part of the problem.  Too much paperwork and complexity in the billing process is one of those few things.  Lately, EMRs have been lavished much of the attention and money; however, medical records are not the problem.  CPT codes are.

For most physicians, Current Procedure Terminology or CPT codes have become a defining aspect of how we must practice medicine.  They have become the “currency” of healthcare, mandating all manner of payments to physicians from the most complex surgical procedures to routine office visits.  In the process, the CPT coding system has turned into an incredibly complex system of codes, modifiers, and exceptions.  Add to that the RVU formulas, and it is no wonder that most physicians are drowning in paperwork.

Physicians feel the impact of this system in their day-to-day practice, especially on cash flow.  Not only do we have to maintain an extraordinary overhead of staff to submit, resubmit and document around CPT codes, the system robs the physician of any leverage we have with payors.  Once we have rendered care for our patients, we must submit (and often resubmit) forms to outside parties to get paid. Make no mistake, the more complex the system, the greater the opportunity payors have to delay and/or refuse payment to physicians, not to mention manipulate those reimbursements to their own advantage, as we have seen in the recent case led by the New York Attorney General against insurance companies.  Their profits grow at the expense of your cash flow.

The negative impact on physicians might be even greater when considering how handicapped physicians are in negotiating reimbursements for a given CPT code.  The current system allows payors to aggregate physician payment statistics, carefully playing one physician off another to negotiate down physician payments, while it is an anti-trust violation for physicians to compare data with one another, much less unionize.  It helps explain why physician compensation goes down every year while demand for those same services continues to explode .

As the national healthcare debate rages on, it is important to recognize that physicians are not the only victims of the CPT codes, the general public is too.  Beyond the massive administrative overhead (it is estimated that 20-50 cents of every healthcare dollar goes to administration), there is something worse, much worse.  The CPT system is privately owned.  Its use is strictly limited so that licensing fees can be obtained.  This has the unfortunate side effect of keeping the general public from doing easy comparisons of healthcare goods and services, also benefitting the insurance companies (who do not want those side by side comparisons because they promote competition and transparency).  There have been many attempts to break the CPT monopoly, most notably by Senator Lott in August of 2001.  Somehow they have always managed to remain in control.  Of course it’s a reliable revenue source.

Beyond offering a tremendous opportunity for improving our healthcare system, one has to wonder why this issue hasn’t been a topic of more focus.  With so much consensus around the excessive complexity and overhead in the billing process, this is completely baffling.  Dentists, lawyers, plumbers pretty much every professional in this country has avoided the fate physicians now face, allowing the market forces of supply and demand to create balance.  Only physicians have seen third parties come between them and their patients.

So who do CPT codes benefit? Well for starters, the AMA receives approximately $70 million in “licensing fees” from anyone who needs to use those codes.  Add to that insurance companies (who pay the AMA many of those millions) who can use the CPT coding system to further their own gains at the expense of the physicians, and it starts to make you realize why CPT codes have been so conveniently left out of the current debate.

So what’s the alternative?  Pretty simple.  Physicians have a service and people are willing to pay for it.  We are the single most critical part of the healthcare system.  We need to start acting like it.  We are at the dawn of a new era in the medical profession.  There is a New Business of Medicine upon us.  Sermo’s data shows that there is a trend towards alternative practice styles (fee for service being among the most prevalent) that is quickly turning mainstream.   To quote another Sermo member, “the new CPT: Cash Please, Thanks.”.  Leave the old CPT to the insurance companies.

The current CPT coding system represents a collusion of convenience between the business side of the AMA and the insurance companies…. at the expense of physicians and patients.  Perhaps most galling, thousands of physicians work on the CPT codes, for which they receive no compensation, while the AMA generates millions of dollars in revenue.  Clearly this presents a massive conflict of interest as the AMA is supposed to be advocating for physicians, yet it receives the majority of its revenues from the very same insurance companies that the rest of the physicians increasingly find themselves facing off against in the deepening healthcare debate.

As overwhelmed as we are with the offers from this community for financial contributions and your willingness to volunteer on behalf of this effort, for now we’d ask that you help us in mobilizing our colleagues in this effort. Remember:

Focus on the things that unite us, ignore the things that divide us. Concentrate on large numbers. Take a stand. Tie a knot.

Daniel Palestrant, MD
Founder & CEO
Sermo, Inc.


Filed under Direct Practice, Innovation, Irony, Medical Home, Value

“Systemness”: Which Delivery Model is Best?

Systemness (sĭs’tə-m nes) adj.

  1. Arrange according to a system or reduce to a system
  2. The degree to which something shares the attributes of a system

Last week I attended the World Health Care Congress Consumer Connectivity conference in San Diego. The Twitter stream was at near flood capacity, and several excellent speakers were present to share their ideas. Conference attendance was affected by the economic climate but I believe the course of dialogue, the information shared, and value of the networking still proved worthwhile.

I shared a panel with Jordan Shlain, MD the founder and Medical Director of Current Health. I served as an advisor to the company through the late summer / fall and participated in their launch in December at World Health Information Technology Conference in Washington DC. Our presentation was intended to focus on “Millennial Technologies for the Medical Home” but given the light attendance, we essentially abandoned our traditional presentation given the intimate setting. After a brief introduction from me regarding the notion of Millennial Patients demanding Millennial Care, Dr. Shlain spent the balance of the session sharing some of the reasoning, thought, and opportunity behind the “direct practice” concept of Current Health.

During the presentation, several examples of “fortress medicine” were shared, including some which highlighted some individual failures and market perceptions with Kaiser and other large providers. The conversation took a couple of pointed turns as several Kaiser employees were in attendance (including an excellent Twitter follow in @janoldenburg). As Dr. Shlain would highlight individual cases which created opportunity for Current, they were countered by persuasive examples and initiatives from the Kaiser team. Abstracting out the tone, the content of the conversation was instructive in terms of alternative models of care.

Integrated health delivery systems deliver better results, period. The evidence is overwhelming as identified by the Dartmouth Atlas and countless other studies. We need to move our country to more “systemness”, which implies coordination, teamwork, shared learning, shared responsibility, and a long term perspective with aligned financial incentives. This is why I love the vision and the promise of true “health systems” like Kaiser, Intermountain Health Care, Group Health, Geisinger, and others.

However, Kaiser and all of these systems, are not perfect (nor claim to be) and despite systemic results that are superior there are individual failings (which seem to find their way into the sensational or anectdotal) that creat opportunities for viable delivery method alternatives. The notion of the medical home, or its complementary concept of Concierge Medicine, is also a “system” of care wherein a single physicians assumes the role of integration and patient experience. Assuming accountability to deliver this “virtualization layer“ enables these physicians to approximate the degree of integration that leads to better outcomes. These organizational delivery concepts have been created to remove the clinical and financial friction and frustration inherent in our current system and deliver personalized care that is safe, effective, patient-centered, timely, efficient, and equitable. We are also starting to see the positive results from these early studies.

The bottom line, we can no longer tolerate our uncoordinated, fragmented, silo’d delivery mechanisms. We must create “systemness” through all the appropriate means as any production organization has had to do as well. The culture of quality and outcomes must be built into the health care processes themselves and their must be rigorous, ongoing improvements with shared learning as the results are captured. This systemness, by any means necessary, will be good for our nations health.


Filed under Current Health, Direct Practice, Health 2.0, Innovation, Leadership, Medical Home, Value

The Health Care Levee – Community Clinics as Medical Homes for the Indigent

Levee (lĕv’ē) n.

  1. An embankment raised to prevent a river from overflowing.
  2. A small ridge or raised area bordering an irrigated field.

The medical home concept is going mainstream. Not only is it a significant part of the Obama teams reform agenda, but it has hitting the front pages much more frequently.  Of interest, Seattle continues to be the hotbed of innovation around this concept (interesting, they are one of the few states that have changed their laws to accomodate “direct practice” medicine), with commercial innovators like Qliance and academic institutions creating new types of practice models.

This article from the Seattle area highlights some early successes working with insurance companies to pay a monthly fee for (a new form of capitation?) services that are increasingly showing a major impact on health (increased communication, care coordination, population/preventative health, etc) but have never traditionally been compensated.

You will recognize this model, “fee for service with a capitated medical home fee” or “compensation for enhanced practice capabilities” (I will actually peel back the onion on what these “enhancements” really are), as the model advocated by Alan Goroll and his associates in Boston. Their model envisions the smoothest path to fundamental reform as being one that works within the current insurance paradigm but with several key improvements over Capitation 1.0. These would include compensation for the enhanced practice capabilites already noted, adjustments according to patient complexity, (they have a fairly elegant patient modifier algorthm), and tying a significant dollar figure to patient satisfaction and ultimately patient outcomes (when they become available). This is a workable approach as long as the payers come to the table which apparently is beginning to happen in Seattle (with at least 50 other “pilots” nationwide).

However, at the same time we are witnessing the above success, we are also seeing Primary Care Clinics being overrun, patients locked out, and system impassibly constipated in terms of new patients moving through.  Increasing access in Massachusetts did nothing to increase capacity. I fear the current economy will only accelerate this based on this report from the California Healthline. This will in turn hurt the most structural at risk part of our health care system – the community  health clinic. These often under-funded, under-staffed, overcrowded, and overburdened facilities are home to some of the most noble of the entire profession who day in and day out slug it out in some very difficult trenches. But they are also some of brightest, most resourceful, and talented clinicians and healers we have in medicine. They represent the levees of our American Health Care system.

But their limited surge capacity will most certainly be overwhelmed in the coming flood of patients being sent their way by the prevailing financial storms. When the flood waters break, I believe Katrina will look like an afternoon shower compared to the vicious cycle of care that will ensue (no primary care, crash in the ER, most expensive place to treat, kicked to the street, no followup, and back to the ER. Rinse. Repeat. Ad Nauseam and Ad Infinitum). Ouch.

Louise McCarthy, vice president of governmental affairs for the Community Clinic Association of Los Angeles, said, “There’s not a very large infrastructure in place to handle the increasing need, even though providers will do everything they can to treat as many people as they can.” Sounds reassuring.

Given that the Community Clinic is the “medical home” of the indigent – what low cost, effective, and useful technology sandbags can be put cobbled together to hold back the waters? I like David Kibbe’s recommendations to Obama as examples of the simple, but far reaching processes that can be implemented to complete the growing support for ubiquitous EHR deployments (about time!).

What other sandbags, or better yet, what infrastructure needs to be put in place to service the Community Health Clinics as a fundamental component of our primary care system?

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Filed under Direct Practice, Medical Home

Hamster Wheel Medicine – Getting off the treadmill

Treadmill  (trĕd’mĭl) n.

  1. An exercise device consisting of a continuous moving belt on which a person can walk or jog while remaining in one place.
  2. A similar device operated by an animal treading a continuous sloping belt.

Today, Dr. Jordan Shlain and I opened the morning session of the 2009 WHIT Conference by introducing the notion of Direct Practice as a model for enhancing access, reducing costs, and improving quality. For this particular audience and presentation, I set the stage by introducing three themes:

  1. Health Care in Crisis
  2. Patients as Consumers
  3. Direct Practice as a Response

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This then set the table for Dr. Shlain to share his 10 year experience as a pioneer in this field. He described very intimate stories of the deep relationships, the personalized service, and the exceptional outcomes achieved. It was a truly powerful way to introduce what we believe will be the next wave of innovation in health care delivery. He closed by publicly unveiling for the first time Current Health (which I profiled yesterday) as the first branded primary care experience coming to a west coast location near you.

[splashcast c SYDW7482IU]

Given the time constraints, we were not able to take all the audience questions. I will post responses to these on shortly:

  1. What application are you using to send data to your iPhone?
  2. How do we get Americans to take care of themselves?
  3. You are speaking about General Practitioner from 80 years ago?
  4. You seem to be talking about non-universal healthcare?
  5. If more primary care docs see fewer patients with your model, how will we meet the burgeoning primary care needs of America?
  6. How many patients do you see at any one time?
  7. How does your model handle emergencies?


Filed under Conferences, Current Health, Direct Practice, Innovation, Medical Home, Quality, Transparency, Uncategorized, Value